第五十章-周围血管和淋巴管疾病说课讲解

第五十章周围血管和淋巴管疾病

1．Try to depict the diagnostic basis of simple superficial varicose veins of lower limbs.

Patients present with superficial varicose veins along the

course of greater saphenous vein and / or lesser saphenous vein

and their tributaries, and complain of heaviness, fatigue of

involved lower extremities should be considered of superficial

varicose veins. Physical examinations revealed superficial

varicose veins along the course of greater saphenous vein and

/ or lesser saphenous vein and their tributaries, some patients

have skin alterations such as pigmentation over varicose veins

in calf, especially at gaiter area. For severe ones, even have

mild edema around ankle and ulcer above medial malleolus level.

Perthes test and Trendelenburg test might be help to identify

the patency of blood reflux in deep vein and valvular function

in perforator, respectively. Duplex ultrasound, venography

will help confirm the diagnosis, and differentiate from deep

venous thrombosis and primary deep venous insufficiency. For

moment, venography is the “golden standard” for the diagnosis

of simple superficial varicose veins.

2. Try to depict the etiology of deep venous thrombosis (DVT) in lower

limbs.

The etiology of deep venous thrombosis (DVT) includes venous stasis, venous injury and hypercoagulation. Any

reasons which can caused abovementioned states will result

in DVT. Long-time bedding, peripheral venous ectasia

caused by epidural anesthesia or general anesthesia, thus

result in venous stasis. Left iliac vein compressed by both

crossed right common iliac artery and the third lumbar

vertebra in about 2/3 population, it’s the most often

location where thrombosis will occur. Intravenous infusion

of stimulus or hyperosmotic solution, venous injury caused

by fracture, local contusion will result in venous

thrombosis. Major operations are most frequent causes for

hypercoagulation. Burn injury or severe dehydration will

pachyhemia, thus result in hypercoagulation. Factors

produced by neoplastic tissue, contraceptive drugs, abuse

administration of hemostatic and dehydrator will also

cause hypercoagulative state in blood. Those factors might

coexist and eventually caused DVT.

3. 一名患者因下肢浅静脉曲张就诊，病史询问、体检要注意哪些方面，进一步

检查需要哪些？考虑哪些诊断？

病史询问需问清病程几年，出现下肢浅静脉曲张前有无同侧肢体肿胀病史，肢体有无发热等不适症状，不适症状在哪些情况下加重，患者从事什么工作，是否长期站立，是否存在慢性咳嗽和便秘。专科体检主要包括患肢是否肿胀，曲张浅静脉分布是否沿大、小隐静脉及属支行径，外侧行径，或无规则分布，或同时伴有毛发增生；皮肤颜色变化，特别是小腿下1/3和曲张静脉上方，是否合并溃疡；皮温变化，曲张静脉部位及周围是否皮温增高或扪及震颤，下肢感觉、运动及动脉搏动情况，并与对侧肢体作比较。如患者下肢浅静脉曲张是沿大、小隐静脉及属支行径，进一步可行血管无损伤检查，包括空气容积描记和超声检查，行初步筛选，进一步明确诊断再行下肢静脉顺行造影，以鉴别单纯性下肢浅静脉曲张和原发性深静脉瓣膜功能不全。如患者下肢浅静脉曲张分布不规则，且既往有下肢肿胀病史，体检患肢可有增粗或正常，则高度怀疑下肢深静脉血栓后遗症，无损伤检查可行空气容积描记和超声检查，明确诊断行下肢静脉顺行造影。如患者下肢浅静脉曲张伴局部皮温明显增高，可及震颤或听诊可及杂音，高度怀疑动静脉瘘或先天性血管畸形。根据患者病史，外伤史初步判断先天性或后天性，无损伤检查可行CT血管成像或磁共振血管成像帮助明确诊断，有创检查包括动脉造影。

4. Try to depict the diagnostic basis of deep venous thrombosis (DVT)

in lower limb.

Sudden swelling and pain in lower limb, that

symptom most often occur in left. For mild cases,

only heavy sensation in lower extremity and will be

aggravated after standing. But for severe cases,

obvious swelling, pain and even arterial spasm

caused by interstitial hyper pressure exist, the

latter is called phlegma cerulea dolens (股青肿),

if left untreated, it will eventually result in limb

gangrene. The life-threatening complication for

DVT is pulmonary embolism. Physical examinations

reveal swelling in involved limb with increased

tissue tension, some patients have tenderness in

femoral triangle or gastrocnemia region. Homan’s

sign is positive in some patients with venous

thrombosis in calf. For later cases, superficial

varicose veins exist. Patient in acute stage

presents sudden dyspnea, thoracic pain, hemoptysis,

cyanosis or shock or should highly suspect of

pulmonary embolism. Further eaxaminations for DVT

include ultrasound and invasive venography, which

will help to confirm the diagnosis.

5. Try to depict the therapeutic measures of deep venous thrombosis (DVT), which include non-operative and operative treatment.

深静脉血栓形成(DVT)的治疗分急性期和慢性期的

治疗，同时急性期的治疗又分为药物治疗和手术治疗。

急性期药物治疗包括溶栓、抗凝和抗血小板治疗。溶栓

药物有链激酶(Streptokinase)、重组链激酶、尿激酶

(Urokinase)、基因重组人体组织型纤溶酶原激活物

(tissue-type plasminogen activator)。其在早期用药

疗效较好，治疗过程中注意局部出血倾向，包括注射局

部瘀斑、伤口渗血、血尿、消化道出血等。抗凝药物有

肝素、低分子肝素和口服的双香豆素类药物，其中低分

子肝素相对肝素为安全，出血副作用较小。抗血小板药

物主要有肠溶阿司匹林、潘生丁等，作为辅助用药。如

患肢肿胀明显，组织张力较高，病程在3天内，或有进

展至股青肿可能或已出现股青肿，则应行积极的手术取

栓治疗，急性期髂股静脉血栓形成，取栓术后疗效较好。

急性期预防肺栓塞可行下腔静脉滤网置入术。慢性期的

治疗以保守治疗为主，可口服抗血小板药物和双香豆素